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Let's hope it's not contagious

Friday, November 30, 2007
 
The Indianapolis Star has a disturbing story about a new Anthem Blue Cross/Blue Shield plan available to businesses who want to further trim their health care costs. The "Blue Access Hospital Surgical PPO" is being rolled out in Indiana, Ohio, Kentucky, Missouri and Wisconsin.


What's new here isn't the fact that Wellpoint-Anthem-Blue Cross is selling these yucky plans. It's easy to find stripped-down plans like this if you have to buy coverage on your own, without the benefit of an employer negotiating a lower group rate. The difference is the fact that they're offering it to businesses as an "alternative'' that costs as much as 70% less than comprehensive plans.

Stats on the "Blue Access'' plan include:


  • DEDUCTIBLES $1,000 to $5,000 (for an individual) and $3,000 to $15,000 (for a family).
  • COPAYS (doctor's office) $20, plus half of the total charge. (This, of course, is after you've paid full price for every doctor's visit until the deductible is met).
  • COPAYS (hospital) $150 co-pay, plus 20% of the total charge (after the deductible is met).
  • COPAYS (generic drugs) $10 in-store, $20 mail order
  • OUT-of-POCKET MAXIMUMS $5,000 (individual), $10,000 (family) -- it's unclear from the story if the out-of-pocket maximums would be on top of the deductible, or include the deductible.

Sooooo...... this development makes it even more important that health reform efforts establish a solid "minimum benefit package,'' which includes doctors and hospital care, preventive care, maintenance of chronic diseases, prescription drugs, and other benefits, that would be credited as coverage. It's only a matter of time before more of these types of plans seep into business' open enrollment packets and head westward.


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posted by Hanh Kim Quach | Permalink | 11:55 AM


 
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At the call of the Speaker...

Thursday, November 29, 2007
 
Shane Goldmacher at Capitol Alert has the scoop on the most recent developments:

The Assembly sessions for December 5th and 6th are now postponed. There was an issue that they conflicted with retreats with the Assembly and Senate Republican caucuses, and it seems they need more time in negotiating on health reform.

We've heard from various Assembly offices that the Speaker has asked members to be available within 24 hours notice.

As Steve Maviglio, spokesman for the Speaker, said:
"We’re still negotiating on health care and we needed additional time to
draft language and shop it around," he said. "We realize we are pushing the
envelope (to still qualify for the ballot). But we’d rather get it done right
than fast."

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posted by Anthony Wright | Permalink | 5:15 PM


 
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How others make it work....

Wednesday, November 28, 2007
 
The Commonwealth Fund has a this handy little compendium that describes how other countries insure their citizens.

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posted by Hanh Kim Quach | Permalink | 12:45 PM


 
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Costing it out...

 
The new Health Wonk Review is up at Health Care Renewal, where our SCHIP post is spotlighted, along with several other posts from around the blogosphere.

An example is Maggie Mahar's HealthBeat critique of the New York Times' full-page editorial on rising health care costs.

I think the NY Times is right that there's no one silver bullet, but there's a legitimate set of proposals that each makes a difference, and together, can make a big difference. Health Access has a fact sheet describing an overlapping set of solutions to rising health care costs--which also dismisses ones that are phony answers as well.

I also agree with Mahar's critique of the NY Times on the details: Prescription drug prices are a bigger deal than you think; that the "skin in the game" idea is vastly overblown; etc. The overall point of nyceve's blistering attack on DailyKos is on point as well, that the insurers and their administrative costs and profits shouldn't be left off the hook.

So there's a lot of work to do. We may not be able to do all of it in one swoop, but let's get started!

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posted by Anthony Wright | Permalink | 12:01 PM


 
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Not just a word, but a challenge

 
As health reform negotiations go on, I continue to be puzzled why the Governor has yet to publicly budge on having some--*any*--affordability standard for individuals in the context of a mandate. Any other politician, concerned about voter reaction, would not just include affordability in their plan, but lead with it. The presidential Democratic candidates, like Clinton, Obama, and Edwards, both provide assurances to voters than coverage will be affordable, both in terms of costs (tied to a percentage of their income), or in terms of benefits (for example, saying that people should have access to coverage as good as what Congress gets).

Some, like health care blogger Alan Katz, have criticized the notion of an affordability exemption--saying it undermines the point of a mandate. The Governor's team asks, "don't you want universal coverage?" Of course, but I think they misunderstand the point.

Our goal is not an exemption. Our goal is to get people covered. The affordability standard is a challenge, to insurers to keep costs down, and to policymakers to provide the subsidies needed to low- and moderate-income Californians.

If we have the cost containment and appropriate subsidies in place, then any mandate--even with an affordability standard--would be universally applied, and everybody would have affordable coverage. We've reached the goal. However, if the costs continue to rise or subsidies are not there, then let's not have an unlimited legal requirement placed solely on individual consumer's shoulders.

There is a conversation to be had about what is affordable, with regards to premiums, out-of-pocket costs, and benefits, but it amazing to me that we are still talking about whether an affordability standard should even exist in the first place.

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posted by Anthony Wright | Permalink | 10:36 AM


 
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Willing, but Unable....

Tuesday, November 27, 2007
 
An article in this month's Health Affairs (subscription required) breaks down why the U.S. Census Bureau's statistic pointing out that one-third of "higher income'' Americans is uninsured is misleading. The Census statistics are an important source for health coverage data and is also used by the federal government to allocate funds.

In 2006, according to Census statistics, more than one in every three Americans (37.8%) lived in a household with income higher than $50,000.


But, the Health Affairs article points out"...many of the uninsured who live in higher income households do not fit a profile of "financially able but unwilling.''
Moments when income is "high" could be a temporary, as with self-employed or transient workers. So are moments of uninsurance, when a person is between jobs.

Additionally, "households'' does not equal "one family.'' Many of these "households" have many generations living under one roof: adult children at home who are contributing to the family income, but are not allowed to glom onto their parents' policy; parents living with their adult children, who need to purchase separate policies. Adults in "high income'' households could also be in roomate situations, and therefore need separate policies. So if you separate out the individual family units, earnings are far below the $50,000 to $75,000 mark.

That's why the debate about affordability of health care in this year's reform efforts is so essential. Policymakers need to find a way to help this middle-income group, sandwiched between super-poor and super-rich find affordable and meaningful health coverage.

As the report shows, being uninsured is not a symptom of being "young, invincible'' and brazen as many would like to believe, but more because insurance simply costs too much for people who are trying to survive by pooling their resources and huddling under one roof.

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posted by Hanh Kim Quach | Permalink | 8:00 AM


 
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Reason #6,089 to reform health care -- this year

Monday, November 26, 2007
 
The California HealthCare Foundation released its annual "Snapshot: California's Uninsured" today and it's grim.

Middle-income families are becoming uninsured faster than any other income-bracket in the state, the report says. Since the beginning of the decade, the number of families earning between $50,000-$75,000 and are uninsured has increased by 3.1%.


This is a really important point because $75,000 is between 350% to 450% of poverty (depending on family size) -- the level at which policymakers are discussing cutting off eligibility for tax credits to help keep the cost of health care affordable. The guv wants he cut-off at 350%, the Democrat leaders want it at 450%. This latest information, to me, makes a convincing argument for the higher threshhold. If the trend continues, as we expect it to, we can only expect more and more middle-income people to be uninsured in future years if something is not done.

Other interesting -- and sobering factoids:

  • Since the beginning of the decade, 5.9% fewer Californains are getting their health coverage through work. Instead, they're getting it primarily from really expensive individual policies (up 2.6%), Medi-Cal (up 2.1%), Medicare or are uninsured.
  • Young adults -- ages 25-34 -- experienced the biggest jump in uninsurance since 2000.
  • Latinos are three ties as likely as whites to be uninsured.

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posted by Hanh Kim Quach | Permalink | 12:03 PM


 
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We're not alone...

Sunday, November 25, 2007
 
The Kaiser Family Foundation has a new interactive map showing what other states are doing on health reform. It's a far cry from when California started this conversation in 2003, where only Maine was having a similar conversation...

Some quibbles: the description of California is short, and neglects key pieces of history and policy. And the map classifies the reforms in Massachusetts, Maine, and Vermont as "universal," which I understand has come to be shorthand for any sort of comprehensive reform package, but I don't think advocates in those states would say their plans are fully universal.

Still, it's useful to get a sense of what is being discussed around the nation...

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posted by Anthony Wright | Permalink | 8:43 PM


 
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Waiting for January 2009...

 
Susan Brink at the LA Times has a lengthy overview of the SCHIP children's coverage crisis, from the point of view of one middle-class family that isn't eligible for children's covearge now, but their kids would be covered under the reform proposals by Governor Schwarzenegger and the legislative leadership, if the federal government gets around to funding the program.

More on the political side, there's an important article by Zachery Coile at the San Francisco Chronicle describing the awful choices that California has with regard to the SCHIP discussion: without a resolution in DC, California is on the brink of disenrolling hundreds of thousands of children from the current program.

As I point out in the article, this goes beyond the awfulness of denying children coverage for their check-ups and emergencies... this undoes ten years of outreach and enrollment efforts to build the program up to this point, to the 800,000+ children now in CA's SCHIP program, called Healthy Families. This is a betrayal of trust... the whole point of insurance is to provide security, and that security is gone when you yank the insurance away. When the funds eventually come in, will we find those kids again? Why wouldn't those families be skeptical?


The only good news is that I think that this problem has a defined end date.

* There's a good possibility that a deal could be worked out in the next few months between the President and Congress that provides the needed funds for SCHIP, especially if there's enough heat on the President, Republicans running for re-election, especially 15-or-so Republican Representatives that would provide the margin for a veto override. The closer this gets to the election, the more Congressmembers on the wrong side of this issue may want a deal to protect them from political attack.

* In the worst case scenario, the problem goes to January 2009, with a new President. The Democratic candidates have already pledged to support the Congressional policy and level of funding. Frankly, I can't imagine that a new Republican President would want to start his new term with a fight over children's coverage (it's still hard to fathom why President Bush has instigated this issue). And the next President, regardless of party, may not have a choice: a newly-elected Congress with different margins may be able to muster a two-thirds override itself.

There's not enough federal money to wait until January 2009. So it's a real, immediate, ugly problem... but one that has a light at the end of the tunnel.

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posted by Anthony Wright | Permalink | 10:49 AM


 
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Thanks and congratulations...

 
With Thanksgiving starting the holiday season, it would be appropriate to send congratulations to some of our friends and allies.

Earl Lui, a former Consumers Union advocate and Health Access California board member, who is now at the California Wellness Foundation, just announced the arrival of his new baby, with his wife Fi.

Dustin Corcoran, from our frequent allies at the California Medical Association, and his wife Glenda, of Assemblyman Hector De La Torre's office, had their first child in the last month as well.

Both babies have scored the jackpot in the parent department.

And all the best wishes to Marin (Bogema) Nakasone, our amazingly adept administrative assistant, who last week celebrated her wedding in their hometown in Hawaii. We hear the bride and the ceremony was beautiful.

We're happy for all of them in their new lives.

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posted by Anthony Wright | Permalink | 9:57 AM


 
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They are on their own...

Tuesday, November 20, 2007
 
The Los Angeles Times has a brilliant article on the major flaw of the Republican presidential candidates: they all are based on expanding the individual insurance market. It's not just the least efficient, most expensive way to get coverage, but in that construct, the individual consumer has the least market power--and thus is able to get denied and discriminated.

Governor Schwarzenegger's original plan had a similar premise, but at least recognized the need to regulate the insurers to stop denials for "pre-existing conditions." The Republican presidential candidates can't bring themselves to do that--which means that McCain, Guiliani, Thompson, all cancer survivors, would all be denied for coverage in their own plans!

The Health Care Policy and Marketplace Review blog also points out the irony of putting forth such proposals with all the headlines about denials of coverage in the individual market.

The Democratic plans, in contrast, are largely based on expanding group coverage, through public programs, employer-based, or a large purchasing pools. To the extent there's an individual market, they seek to fix it, and to shrink it. In both cases, cancer survivors like Guiliani, McCain, and Thompson would be assured access to coverage.

Of course, there could always be an exception...

posted by Anthony Wright | Permalink | 6:43 PM


 
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Giving thanks for more time...

 
After lots of scrambling in the past week, folks were still wondering how this would come together for a full Assembly vote on a new version of AB x1 1 on next Monday, immediately after the Thanksgiving holiday.

Well, it's been rescheduled. We are now looking at December 5th or 6th for an Assembly floor vote, and Senate committee and floor votes soon afterwards.

The delay is a good sign. It means that there's still interest in a deal. And it might mean that some of us can actually make Thanksgiving with our families.

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posted by Anthony Wright | Permalink | 3:17 PM


 
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And then what?

 
The America's Health Insurance Plans is patting itself on the back for discovering that the majority of high-deductible health plans, which are connected to Health Savings Accounts, cover recommended preventive benefits -- meaning that patients can go in and get pap smears, well-baby visits, colonoscopies without having to pay full price for the office visit.

Okay..that's a good start. But what happens when your preventive screening shows you have Diabetes? Asthma? Breast Cancer? Then what?

Herein lies the problem. Actually, there are a couple problems.

First, while more than 90% of HSA-eligible plans offered through employers covers preventive care -- most of these plans are purchased through the individual market. There, only 59 percent of policies offer preventive care, meaning that 41 percent of those with these plans don't have preventive coverage.

Secondly, in consumer-speak, "preventive care'' means not only the preventive screening for diabetes, but it also means coverage for insulin shots and other medications to "prevent'' further illness. In the industry, however, it's called "chronic disease maintenance,'' which is NOT covered.

So consumers may be buying these plans believing that they'll have coverage for all their meds and follow up doctors visits because it includes "first-dollar coverage for preventive care'' but it's not the care they think it is.

I'm looking forward to the press release from AHIP that says 100% of plans pay to keep people healthy.

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posted by Hanh Kim Quach | Permalink | 10:54 AM


 
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Slipping down the slope

Monday, November 19, 2007
 
The number of small employers offering health coverage to their employees slipped again to 61 percent. That's down from 69 percent at the beginning of the decade, according to Mercer Human Resources Consulting.

The survey, released today, contains a number of other sobering stats:
  • Among big companies, deductibles rose by 11 percent to $473 for individuals, $1,134 for a family.
  • Small company deductibles rose at a slower pace, but still tend to be higher at $872 for individuals and $1,879 for families.
  • Underinsurance -- through consumer directed health plans -- rose by 5 percent

While employers are currently saving money by having more workers enroll in consumer-directed plans and shifting more costs to workers, the savings are only a short-term benefit, another human resources consulting firm has noted.

"It's critical that companies design their health care programs in a way that encourages employees to use them -- and use them wisely. Otherwise, they are essentially trading preventative care now for 'rescue care' later, which will lead to unhealthy employee populations, a decrease in employee productivity and ultimately -- higher health care costs,'' said Jim Winkler, with Hewitt's Health Management Consulting.

On that gloomy note, I really hope something happens this year.

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posted by Hanh Kim Quach | Permalink | 1:13 PM


 
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Found wisdom...

Sunday, November 18, 2007
 
Went to Chinese last night with the family. My fortune cookie had this message:

Focus on your long-term goal.
Don't hesitate to act now.

posted by Anthony Wright | Permalink | 11:56 PM


 
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Caring about Cultural Competency

 
The San Francisco Chronicle has another great story about Healthy San Francisco, with a focus on cultural competency.

We fully expect that as new people come into the health system, the health system will have to adapt accordingly, to deal with populations that have different language and cultural needs. Health Access has been active in helping public systems (and San Francisco specifically) meet the language access issue, with the new technology of Video Medical Interpretation that we have been pioneering. It's essential as the first clinic was opened in Chinatown.

But it's not just a language barrier, as the article makes clear. Cultural competency matter.

posted by Anthony Wright | Permalink | 11:56 PM


 
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Who's disclosing to whom?

Friday, November 16, 2007
 
HealthNet just got slapped with a $1 million fine for not being candid with DMHC regulators about their policy of offering bonuses for retroactively denying patients. Here are reports by Daniel Costello in the Los Angeles Times and Victoria Colliver in the San Francisco Chronicle.

The irony, of course, is that HealthNet justifies these recissions by saying that patients were not candid about their health status. Amazing.

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posted by Anthony Wright | Permalink | 5:11 PM


 
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The attack from the right...

Thursday, November 15, 2007
 
The so-called Consumer Alliance for a Strong Economy has two radio ads up on their website, attacking health care reform.

This is a shady conservative outfit that doesn't reveal its members or funding sources, and that has put out similar "ads" both against Prop 72 in 2004, and against Governor Schwarzenegger's plan right after his announcement earlier this year. In neither case did the ads get much traction, or get much actual placement in the media.

As for the substance, the ads are not very original, attacking reform with ideological bromides like "government-run health care." No one said that 30-second ads increases the tenor of dialogue.

posted by Anthony Wright | Permalink | 10:28 PM


 
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Elevating the debate...

 
Shane Goldmacher at the Sacramento Bee's Capitol Alert noted that the legislative leaders from the two parties had two very different views of the world, as demonstrated by the headlines of their press releases yesterday. Guess who said what:

Speaker Núñez’s and Senator Perata’s Groundbreaking Health Care Proposal Clears Assembly Health Committee

DEMOCRATS KILL REPUBLICAN REFORM MEASURE, PASS COSTLY GOVERNMENT-RUN HEALTH CARE SCHEME

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posted by Anthony Wright | Permalink | 2:14 PM


 
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Geek love...

 
The new version of Health Wonk Review is up by Maggie Mahar at HealthBeat. She highlights a recent post of ours, saying that it "offers the clearest explanation I’ve seen of Governor Schwarzenegger’s plan for reforming care in California, and its merits and limitations when compared to both HRC’s proposal and the Romney plan in Massachusetts."

Lots of good links, especially about the federal health reform conversation...

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posted by Anthony Wright | Permalink | 2:43 AM


 
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One more time, with feeling...

 
HEALTH ACCESS UPDATE
Thursday, November 15, 2007


HEALTH REFORM BILL ADVANCES IN SPECIAL SESSION
* Assembly Health Committee passes Democratic leadership’s health measure, ABX1 1
* 60 witnesses testify for over three hours
* Floor vote set for week after Thanksgiving

New on the Health Access Weblog: More on the Hearing; How the Budget Crisis Impacts Reform; Reporter Snarkfest; Crossing Off the Gov's AB8 Veto Reasons; The Gov's Counteroffer; Bonuses for Retroactive Denials?; Initial Reaction's to Nunez's New Proposal;


For another time this year, the Assembly Health Committee Wednesday passed comprehensive health reform legislation aimed at expanding coverage to a significant swath of California’s 6.5 million uninsured. The newly reconstituted Assembly Health Committee voted on the first health reform bill of the special session, ABX1 1 (Nunez/Perata) and vowed to send the bill to its Senate counterpart by the end of the month. The bill passed on a 10-5 party-line vote.

The committee also rejected a Assembly Republican promote, AB X1 8, which opponents said would decimate the state’s HMO Patient Bill of Rights and other consumer protections, and promote high-deductible health plans through Health Savings Accounts, leaving more people underinsured in the state.

AB X1 1 goes beyond the ideas layed out in the previously passed – and vetoed -- AB8 (Nunez/Perata) and Gov. Arnold Schwarzenegger’s own health care proposal, formally released and debated last month. In spite of its many iterations, Assembly Speaker Fabian Nunez stressed that ABX1 1 is still a work in progress. “What you have here is not a perfect document, but I would ask everybody to always compare it to the current health care system,’’ he said.

To get a more comprehensive analysis of what’s in ABX1 1, click here. In summary, ABX1 1 would:

* Significantly expand public programs to include:
* Children and parents up to 300% of the poverty level ($61,950 for a family of four),
* Childless adults up to 250% of the poverty level ($25,525 for an individual),
* And tax credits for families between 250% and 450% of poverty to help ensure that the cost of health care does not exceed 6.5% of income.
* Establish a minimum employer contribution of 6.5% for businesses with higher than a $250,000 payroll. Businesses with a smaller payroll would pay less.
* Require all Californians to have health coverage, as long as it was “affordable.’’ “Affordable” means that a family pays no more than 6.5 percent of its income on premium and out-of-pocket costs.
* Require insurance companies to sell coverage to every Californian, spend 85 cents of every premium dollar on health care and prohibit companies from charging sicker enrollees higher rates.
* Create a state-run insurance purchasing pool that would allow Californians to benefit from group negotiated rates.
* Contain the underlying costs of healthcare through public disclosure of cost and quality, bulk purchasing of prescription drugs, and the offer of a public insurer option.
* Establish a $2-per-pack tobacco tax and 4 percent fee on hospitals, in addition to federal, local, employer, and individual contributions to pay reform.

DEBATE AND DISCUSSION

Many Republicans raised the concerns expressed by business interests. Some raised the specter of the Employee Retirement Income Security Act, ERISA, which bans states from explicitly dictating how businesses spend money on specific health benefits. Others also worried that small businesses, working on thin margins, would not be able to afford the coverage.

“Small businesses are saying the 2% fee (on a payroll of less than $100,000)would harm them. They tell me they’ll lose 295,000 jobs,’’ said Assemblyman Alan Nakanishi, R-Lodi.But Nunez said the plan falls apart otherwise. “The only way we can make this work is if everyone has a role,’’ he said.

On the ERISA question, Nunez responded: “We’ve had a roomful of lawyers who have been working with us …we’re not asking employers to pay for specific health care services.’’ Nunez is referring to ERISA provisions that say states can’t prescribe benefits packages, as multi-state companies would need to adjust health coverage from state to state to meet different mandates. (For one take, visit the Health Access WeBlog for our previous analysis of the Maryland decision here.)

Assemblyman Bob Huff, R-Diamond Bar, warned that relying on the tobacco tax to finance health reform was unwise, given that the numbers of smokers has steadily declined over the years, and a severe jump in tobacco taxes would drive more to quit – reducing the amount of revenues the state would draw from such a tax. To that, Nunez jokingly asked whether Huff would agree to support an even higher tax – at $3 to $4 per pack. Seriously, Nunez said he and staff were aware of the fact that tobacco taxes were a declining revenue source, but expected the hospital fee to increase ovcer time and offset the losses from tobacco, along with the kicking in of other reforms.

Assemblywoman Audra Strickland, R-Thousand Oaks, was unconvinced and asked whether the speaker had considered what would happen if health costs continued to exceed revenues. Nunez’ staff responded that MIT economist Jonathan Gruber – who had modeled the numbers for both the administration’s and legislative proposals – had taken the most conservative route in estimating costs. Gruber had “overestimated costs’’ by assuming that none of the cost containment provisions saved any money and “100% of the costs show up the first day’’ something that never happens in a program of this scale that requires years to operate at full capacity.

In light of yesterday’s Legislative Analyst’s Office’s fiscal forecast predicting a $10 billion budget shortfall over the next two fiscal years, Republicans also said this was not the time to be embarking on an ambitious quest to provide health care for all, even though Gov. Schwarzenegger said last week that health reform would actually help rein in costs by assuring the state spent health care money wisely and efficiently.

Assemblyman Hector De La Torre, D-South Gate, pointed out that because ABX1 1, if passed, would not be fully implemented until July 2010, the state had time to address budget issues and its deficit before the full reform was implemented.Democrats on the committee, while supporting the bill and health reform, also advocated for specific amendments.

De La Torre, said he was concerned that the bill did not specifically spell out what kind of benefit package consumers would be buying, even though they’d be required to receive coverage. The problem is that “affordable’’ health plans, are also those that cover few benefits and leave consumers on the hook for more health care costs – rather than less. “We need to try to do something to clarify the quality of the health insurance options – that it isn’t OK to offer a $10,000 deductible and have the policy be acceptable and have that work for the employee,” he said.

Assemblyman Dave Jones, D-Sacramento, author of AB1554 that would have required state approval for every health premium increase said he felt strongly that insurance companies needed to justify their need for premium increases.

Assemblywoman Patty Berg pointed out the irony of discussing health reform while the state has approved emergency regulations to disenroll eligible children from Healthy Families and put other eligible children on waitlists until money from the federal government State Children’s Health Insurance Program is hashed out and becomes available and reliable. (Read more about SCHIP here).

Assemblyman Ed Hernandez, an optometrist, said he worried about the availability of providers to care for newly insured. Assemblywoman Karen Bass said she hoped the state would also track health disparities among ethnic groups.

OTHERS WEIGH IN

Feelings about ABX1 1 were also diverse among advocates and interest groups. Positions on the measure fell under five categories: Support, Support if Amended, Concerned, Oppose Unless Amended, and Oppose.

SUPPORT: Organizations that supported the measure generally supporter the notion that the package sought provide universal coverage. This included the California Association for Nurse Practiioners, American Nurses Association and the consumer group CALPIRG.

SUPPORT IF AMENDED: Organizations in this category also felt that ABX1 1 possessed many features that made it appealing – including insurance market reforms, broad public program expansions and a leap toward universal coverage. But advocacy groups in this category were waiting to see the complementary ballot measure language as well, and wanted some issues remained unresolved – such as affordability and a defined minimum benefit package. Organizations that weighed in as “Support if Amended” included: Health Access California, California Medical Association, California Labor Federation, AFSCME, Consumers Union, Small Business Majority, California Association of Public Hospitals, California Hospital Association, AARP, Congress of California Seniors, Service Employees International Union, Children Now/100% Campaign, Children’s Specialty Care Association, Children’s Hospital Association, California Chronic Care Coalition, ACORN, Unitarian Universalist Legislative Ministry, Latino Coalition for a Healthy California, Alzheimer's Association, Latino Issues Forum, California Federation of Teachers, and the California Primary Care Association.

CONCERNED: Organizations in this group said they were not prepared to take an official position on the bill, yet, but said lawmakers needed to be mindful of the populations they represented and specific concerns they sought to raise. This included Western Center on Law and Poverty, an organization representing Christian Scientists, Los Angeles County, the California Immigrant Policy Center, Blue Shield of California, California Pan Ethnic Health Network, Greenlining Institute, LA Health Action, the Academy of Family Physicians, and the American Cancer Society.

This group also included Jennifer Kent of the Department of Health , representing the Schwarzenegger Administration, acknowledging the progress that the Democratic legislative leadership had come in dealing with the Governor's issues, such as with guaranteed issue and Medi-Cal rate increases. She also reiterated where the Governor had adjusted his proposal (most notably last week in agreeing that the employer fee should go as high as 5.5% of payroll, and that subsidies should go to people up to 400% of the federal poverty level.) While her tone was positive, she did express concerns about where differences remained, including with the exemptions to the individual mandate in AB x1 1.

OPPOSE UNLESS AMENDED: Some business and industry groups fell into this category, including groups that stated their desire for health reform but had significant issues remaining. This included the Safeway-led Coalition to Advance Healthcare Reform, Small Business California, Kaiser Permanente, who did not want any individuals to be exempted from an individual mandate, if insurers were going to be asked to provide coverage to everyone, and Protection and Advocacy Inc., representing Californians with disabilities.

OPPOSE: Most organizations and industries in this camp opposed the previous reform proposal by the legislative leadership, although for different reasons from each other. They included: the California Restaurant Association, California Nurses Association, Association of Life and Health Plans, Foundation for Taxpayer and Consumer Rights, Blue Cross of California, National Federation of Independent Businesses, Chamber of Commerce, California School Employees Association, Howard Jarvis Taxpayers Association, California Association of Health Plans, California Manufacturers Association, Gray Panthers, Butte County Health Care Coalition, and California Small Business Association.

(Of interest, Blue Cross said that nearly 600,000 policyholders would hold plans that might disqualified under ABX1 1 – implying that two-thirds of its individual insurance policy holder are underinsured.)

WHAT’S NEXT: The Assembly is expected to return November 26, at which time AB x1 1 will be amended, and considered in both Appropriations Committee. In that week after Thanksgiving, the Assembly is expected to vote on the measure, and assuming approval, pass it through to the Senate. Speaker Nunez seemed committed to placing a version of AB x1 1 on the Governor's desk in the next few weeeks.

If the Governor were to sign a version of AB x1 1, the expected plan would be to have most or all of the proposal be enacted only if and when a ballot measure would be passed with the financing elements of the proposal. If an agreement if reached, the Governor and legislative leaders, along with a coalition of supporting stakeholders, are expected to campaign for such a ballot measure to be slated for November 2008.

For more information, contact the author of this report, Hanh Kim Quach, policy coordinator, Health Access California, at hquach@health-access.org.

To view other resources from the Year of Health Reform, visit our website, at:
http://www.health-access.org/advocating/2007_healthdebate.html.

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posted by Anthony Wright | Permalink | 2:25 AM


 
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Next steps...

Wednesday, November 14, 2007
 
We're about to post the full update from today's hearing.

The results were not surprising: the Democratic leadership bill passed, the Republican bill failed. No amendments were taken, because of technical reasons having to do with the lack of a legislative quorum. We expect that there will be significant amendments made on November 26th, as they prepare to hold an Appropriations Committee and a floor vote, in that week after Thanksgiving.

More to come...

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posted by Anthony Wright | Permalink | 11:50 PM


 
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Hearing test...

Tuesday, November 13, 2007
 
We understand that the Assembly Health Committee will hear both AB x1 1 (Nunez/Perata) and AB x1 8 (Villines) tomorrow. There is not expected to be consideration of AB x1 2, the Governor's proposal that does not have an author to advance it, and that was the subject of lengthy testimony last week.

Health Access California will by "support if amended" on AB x1 1, the legislative leader's proposal. The framework and many of the specific policy positions are the ones that we have supported in numerous previous proposals, but we are seeking some amendments and clarifications, and really need to see the whole package--including the ballot language, in order to be fully on board.

We were also prepared to support AB x1 3 (Dymally)--although we understand it won't be heard tomorrow. It would have helped reform the MRMIP program for those who are "medically uninsurable" and need some access to coverage. It's a proposal that we may need to come back to if we don't accomplish major health reform that includes guaranteed issue.

We are opposed to AB x1 8, the Republican leaders' package, which we view as mostly encouraging high-deductible health plans through the tax code, and undermining the HMO Patient Bill of Rights and other consumer prorections. We agree with the bill's goal to increase Medi-Cal rates, but the proposal lacks any way to pay for it. The Governor and the legislative leaders both include increased Medi-Cal rates as part of their proposal, but they stepped up with the financing.

Should be an interesting day.

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posted by Anthony Wright | Permalink | 5:34 PM


 
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Top billing...

Sunday, November 11, 2007
 
Here's the text of the legislative leader's proposal, AB x1 1: The California Health Care Reform and Cost Control Act.

It's important to note that there are elements of what the legislative leaders put out in their framework that isn't in the bill. Some of those parts are slated to go into a separate ballot measure document; For other parts, it's simply that they didn't have the time to draft it.

The next opportunity there will be for Speaker Nunez to amend the bill will be next Wednesday, November 14th, in the Assembly Health Committee.

Also that might be heard:
The Governor's proposal, in bill form but without an author, is AB x1 2.
Republican Leader Villines' package, ironically numbered AB x1 8.


It's getting real...

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posted by Anthony Wright | Permalink | 12:45 AM


 
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Responding to the snarkfest...

Saturday, November 10, 2007
 
The KQED Capitol Notes Podcast this week perhaps features the three snarkiest reporters in the Sacramento press corps, all good but perhaps more cynical than necessary.

They were skeptical of the argument, advanced by the Governor and others, that the looming budget crisis actually compels us to do health reform. He made this argument most recently at his speech at the conference Latino Coalition for a Healthy California, a member and ally.

Here, I actually agree with the Governor: the budget deficit makes health reform harder, but more urgent. It's the only way to bring in new money--including federal matching funds--into California. Obviously, it means we'll have new obligations, but without reform, we'll be looking at severe health care cuts. Health care is around one-third of the state budget--getting revenues for it helps the entire budget.

Even this year, if we don't have health reform, then this year will simply mean a step backwards on health care, with the zeroing out of fund for outreach for children's enrollment and the prescription drug discount program, and the looming SCHIP issue threatening to disenroll children from Healthy Families. The question is whether 2007 will be known for taking steps forward, or steps back.

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posted by Anthony Wright | Permalink | 11:30 PM


 
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Why not sign?

 
We are still looking at the details of AB x1 1, but it's clear that the framework proposed by the Legislative leadership addressed all of the Governor's reasons for vetoing AB8 (Nunez/Perata).

The Governor's announcement on Thursday that he moved to a more realistic employer fee was important, but it was probably more significant that he drew some constrasts as well. He felt he needed to, because otherwise, there would be no reason why he shouldn't agree with the framework of the Nunez/Perata proposal.

Let's look at his veto statements, and the framework of AB x1 1. From the Governor's press release detailing his reasons for vetoing AB8: "Governor Arnold Schwarzenegger today vetoed AB 8, by Assembly Speaker Fabian Núñez (D-Los Angeles) and Senate President Pro Tem Don Perata (D-Oakland), a bill that does not cover all Californians, does not address the key issues to reduce health care costs and places too much of the financial burden on employers." Let's do this one at a time:

"This bill does not achieve coverage for all – a critical step needed to reduce health care costs for everyone."

* AB x1 1 would provide more help to more Californians than the Governor's own plan, in three ways:
* It extends public programs to 300% of the federal poverty level, rather than the Governor's 250%.
* It extends subsidies to people up to 450% of the federal poverty level, rather than the Governor's 350% or 400%.
* It does a better job of encouraging employer-based coverage, with a higher minimum employer contribution and a two-pronged test to ensure that spending is spread among the employers' workers.

"Instead, AB 8 puts more pressure on an already broken health care system and places an unreasonable financial burden on businesses. A 7.5 percent fee would force employers to shoulder the entire burden of health care reform – a devastating blow to small business in California,”

* AB x1 1 lowers the employer fee down to 6.5%, with a sliding scale for small employers.
* The statement was incorrect, since the employer fee made up half the revenues of the health care plan, alongside several other funding streams, including individual contributions, federal matching funds, reinvested state savings, Section 125 tax breaks, and an insurer assessment.
* AB x 1 1 adds to that mix with additional sources, including a tobacco tax, a hospital fee, additional federal matching funds, more individual contributions, and reinvested savings potentially from counties. As a percentage of the overall package, the employer fee is a fraction of the overall revenues.

From http://www.fixourhealthcare.ca.gov/, here are other principles the Governor laid out in response to AB8:

1. Guarantees that every Californian can get insurance. Under the Governor's plan, insurers will be required to sell insurance to anyone who wants to buy it on the individual market. "Guarantee Issue" will give Californians who are currently denied coverage because of their medical history or age the ability to purchase insurance.

* AB x1 1 also gives all Californians the ability to purchase insurance.

2. Provides coverage for all and requires that every Californian have insurance. Whether they get it through their employer, buy it on the individual market, or enroll in subsidized coverage, every Californian must carry a minimum level of insurance under the Governor's plan. This will reduce the hidden tax that insured individuals and families -- and employers who provide insurance -- now pay to cover the uninsured.

* AB x1 1 has an individual mandate, tied to affordability.

3. Increases Medi-Cal reimbursements to doctors and hospitals. The Governor's proposal significantly increases Medi-Cal reimbursements by the government to doctors and hospitals, reducing their need to shift costs onto insured individuals, families and employers.

* AB x1 1 has a hospital fee and a corresponding Medi-Cal rate increase.

4. Promotes balanced financing for health care. Health care reform should not come by requiring employers to pay the entire cost.

* AB x1 1 has at least eight different funding sources, with employers being a fraction of the revenue.

5. Rewards healthy choices and contains costs. The Governor's plan outlines a comprehensive prevention policy that encourages and rewards healthy behaviors; supports new efforts to fight chronic conditions including diabetes and obesity; reduces smoking; promotes more efficient service delivery and will help prevent medical errors.

* AB x1 1 has all the prevention and cost containment concepts of the Governor, and others with more teeth, including ensuring transparency of health cost and quality; bulk purchasing of prescription drugs, and the option of a public insurer.


With all this agreement, the Governor will need to sign the proposal heading toward his desk, or think of new reasons to object...

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posted by Anthony Wright | Permalink | 11:01 PM


 
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Infuriating Incentives

 
This Los Angeles Times story by Lisa Girion is getting justified attention around the blogosphere (from Weintraub to Hagey to Rosen to Holt) and around the country (I just got off the phone with someone from New York who saw the article).

It reveals the scandalous practice that Health Net actually paid *bonuses* for retroactively denying people. If nothing else, it raises why we allow insurers to deny people based on "pre-existing conditions" in the first place.

The link has a "Related Stories" archive of many past Girion articles that lay out a convincing case against the individual market, the way insurers do business, and the insurance industry itself.

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posted by Anthony Wright | Permalink | 10:29 PM


 
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The Gov makes a move...

Thursday, November 08, 2007
 
The Governor revised his proposal today on a few issues in the health reform debate, moving toward the Democrats on a couple issues. But he also unproductively drew some lines in the sand at the same time, which is not helpful in getting to a deal, or for that matter, to a good policy.

The positive movement:
* He would increase the minimum employer contribution to 5.5% of payroll, up from his original proposal of 4%. (This is still under the 6.5% that the Democratic leaders had alreadly lowered from their previous proposal. The Gov would also include broader accomodations for small business than the Democratic proposal.)
* He would increase subsidizes for coverage to families up to 400% of the federal poverty level ($40K for a individual, $82K for a family of four). This is up from his revised proposal of 350%, but less than the 450% in the Democratic proposal.

The nonproductive statements:
* He opposes the two-part test in the Democrat's plan to make sure than employers spread the benefit of their health care spending among all workers, including part-time and low-wage workers.
* He wants to lock-in the employer fee, only to be changed with a 2/3 vote--meaning that for all practical purposes, it will never be able to be adjusted to meet a changing health care environment.

So close and yet so far...

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posted by Anthony Wright | Permalink | 7:11 PM


 
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Reaction to the legislative leadership proposal...

Wednesday, November 07, 2007
 
Shane Goldmacher, liberated from behind the pay curtain of the Sacramento Bee's Capitol Alert, has compiled many of the organizational responses to the legislative leaders' new health reform proposal. While many groups are waiting until they see the actual legislative language, there's many positive responses, although it's not without criticism from both the right and the left.

Some editorial boards also have weighed in, generally positive--even those that have historically editorialized against health reform. At part of the funding mix, they seem to like the tobacco tax better than the Governor's proposal for leasing the lottery.

All sides recognize that Nunez and Perata have made huge movement, and so it's all up to the Governor to embrace the framework and hammer out the details. The Sacramento Bee headline says it all: "Your turn, Governor." The San Jose Mercury News notices that the Governor seems ready to make a deal, at least in his recent public comments, but now it's time for action, action action.

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posted by Anthony Wright | Permalink | 10:50 PM


 
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The comparisons...

 
HEALTH ACCESS UPDATE
Wednesday, November 6, 2007


DEMOCRATIC LEGISLATIVE LEADERS INTRODUCE NEW HEALTH PROPOSAL
* AB x1 1 Would Significantly Expand Public Programs; Subsidies for Coverage
* Would Require Californian to Have Health Insurance, But Conditioned on Affordability
* Answers Critique by Governor in Veto of AB8, the Legislative Leaders’ Previous Proposal
* Hearing Scheduled for November 14th

New on the Health Access Weblog: More Analysis/Commentary of Nunez's New Proposal on Health Reform; Breaking News on the Special Session, including new Assembly Health Committee: More on SCHIP and the Fallout from the Bush Veto;


Democratic legislative leaders on Tuesday announced out their latest health reform proposal, as the framework for a potential agreement with Governor Schwarzenegger. The press release is available at the website of Speaker Fabian Nunez.

The framework would provide more help to more Californians in getting affordable coverage than either the Governor's plan or the legislative leaders' previous proposal, AB8. It also moves in the direction of the Governor's proposal in key areas, including spreading the financial burden among a broader range of contributors, and introducing a requirement that all Californians buy health coverage--although only if coverage is deemed affordable.

The new bill, AB X1 1 (the first bill in the first extraordinary session of the legislature) will be formally introduced as legislative language later this week. It is expected to be heard in the Assembly Health Committee hearing on November 14th. Financing elements of the plan, which include a hospital fee, employer fee and a $2-a-pack tobacco tax, would appear before voters in November 2008.

THE HISTORY: The latest proposal, by Assembly Speaker Fabian Nunez and Senate Pro Tempore Don Perata, is the latest legislative volley in the health reform debate, which began nearly a year ago when both leaders introduced separate plans. That was followed by the governor’s January release of a 10-page concept paper. The leaders then merged their plans into one bill, AB8, sent that to the governor, who vetoed it in October. That same week, the Governor finally released the legislative language of his proposal, which largely mirrored his January proposal. This new proposal is the legislative leaders' attempt to deal with all the issues raised by the Governor in his veto of AB8.

THE PRESS CONFERENCE: Assembly Speaker Fabian Nunez hailed his proposal as a "breakthrough," and mentioned that "the tumblers are falling into place," and when the Governor moves, California "will finally unlock" the puzzle of health care reform. Senate President Pro Tem Don Perata acknowledged that "we've been doing this a long time," and "if it was simple, it would be done: it's not simply, and it's not done." But again, he emphasized that this would be the framework of a deal with the Governor, if the Governor met them with the significant steps that they took.

SUBSTANCE: WHAT’S IN THE BILL: Many of the concepts in the latest proposal closely follow what lawmakers have been discussing all year, with some adjustments:

PUBLIC PROGRAM EXPANSION:

* AB X1 1: The proposal include a major expansion of public program and subsidized coverage to low- and moderate-income Californians, and not just to children and parents, but the adults without kids at home. It includes: All children, regardless of immigration status, up to 300 percent of poverty. Parents of those children who are citizens or legal residents (up to 300 percent of poverty) would also receive coverage. Single, childless adults below 250 percent of poverty – many of whom currently can’t afford coverage, but don’t qualify for public programs now at all – would now qualify for Medi-Cal. The proposal also includes streamlining of these programs so that those eligible for the program can more easily get on and stay on. Individuals with incomes between 250% to 450% of poverty would receive a new tax credit to assure that coverage through the purchasing pool would not exceed 6.5 percent of income for overall health care costs.
* CHANGE FROM AB8: The proposal goes beyond AB8 with expansion of Medi-Cal to adults without children at home, funded by the new revenues raised. Another new element is the advanceable, refundable tax credits to ensure affordability for families up to 450% of the federal poverty level, or $92,925 for a family of four.
* DIFFERENCES WITH GOV’S OCT. PROPOSAL: The Governor's plan expands public program coverage for parents up to 250 percent of poverty ($51,624), rather than 300 percent ($61,625) under AB X1 1. The Governor's plan has subsidies through tax credits between 250 to 350% of poverty to buy coverage, rather than up to 450% in AB x1 1. That tax credit would make the cost of the premium 5 percent of the family’s income, but that credit would not take into account out-of-pocket costs.
* COMMENT: The proposal would be the largest public coverage expansion since the creation of Medicare and Medicaid 40 years ago. Millions of Californians would have access to get comprehensive coverage through Medi-Cal or Healthy Families.

MINIMUM EMPLOYER CONTRIBUTION

* AB X1 1: A sliding scale up to 6.5% of payroll. Employers with a payroll higher than $250,000 annually would be required to pay 6.5 percent in health benefits. Businesses with smaller payrolls would contribute on a sliding scale (Less than $100,000 payroll would pay 2 percent for health benefits, between $100,000 and $250,000 would pay 4 percent for health benefits). Employers would have a two-pronged test to ensure that the benefit was being broadly shared among all workers. As part of this two-pronged test, they would have the option of providing private coverage or paying a fee into a statewide purchasing pool for those earning more than $25,000, AND for those earning less than $25,000.
* CHANGE FROM AB8: The previous proposal required all employers – regardless of size and payroll – to pay 7.5 percent for health benefits.
* DIFFERENCES WITH GOV’S OCT. PROPOSAL: The governor’s proposal requires an employer contribution of 4 percent of payroll if a business has more than 10 employees. Businesses with fewer than 10 workers would pay between 0 percent and 4 percent. Even if a business pays into the purchasing pool, their workers would not qualify to receive coverage from the pool if the worker doesn't meet the standard income requirements for public program coverage or subsidies.
* COMMENT: The employer contribution is lessened to deal with the concern raise by Governor Schwarzenegger in his veto message, but it still provides employers a new, affordable option by which to cover their employees. Having a group purchasing pool, and a sliding scale contribution level allows businesses to actually provide a benefit that might otherwise be out-of-reach. Additionally, ensuring that businesses pay on both their lower-wage (less-than $25,000 earners) and higher earners assures that everyone benefits, not just the high-earning or longest-serving workers.

INDIVIDUAL RESPONSIBILITY:

* AB X1 1: All Californians would be required to have coverage as long as the premiums plus out-of-pocket costs do not exceed 6.5 percent of a person’s income. In addition, those within the requirement can apply for a hardship exemption. Those who do not comply would be automatically enrolled in the purchasing pool.
* CHANGE FROM AB8: Required only workers to accept coverage offered to them on the job if the premium and out-of-pocket costs were less than 5 percent of wages.
* DIFFERENCES WITH GOV’S OCT. PROPOSAL: Every Californian would be required to have coverage, without exception, limit, or condition. No considerations for affordability or hardship.
* COMMENT: Consumer advocates have been wary of an individual mandate that would force Californians to buy coverage that was unaffordable, or that they had been denied, or was too complicated to use and keep. AB X1 1, however, addresses many of those concerns by ensuring that Californians would be exempted from the mandate if it is deemed unaffordable. Most Californians, after all, want health coverage; but often, it is unavailable or unaffordable. Additionally, AB X1 1 would establish new rules for insurers, restricting their ability to deny enrollees for so-called “pre-existing’’ conditions. More details are being sought about the minimum coverage level (although requiring high out-of-pocket cost plans will be prevented by the affordability protection).

PROVIDER RATES

* AB X1 1: Would raise Medi-Cal rates, as part of the package with the hospital assessment and the drawing down of federal matching funds for California.
* CHANGE FROM AB8: AB8 didn't include the Medi-Cal rate increase and hospital assessment, due to inability to get the needed 2/3 vote.
* DIFFERENCES WITH THE GOV'S OCT PROPOSAL: Essentially the same proposal.
* COMMENT: California has some of the worst Medicaid reimbursement rates in the country. This will allow those on Medi-Cal to have better access to providers, and better fund the health system we all rely on, by drawing down California's fair share of federal matching funds.

FINANCING

* AB X1 1: There is a multiplicity of eight different funding sources, including an individual contribution (capped at 6.5% of income), an employer contribution (sliding scale up to 6.5 of payroll), a hospital fee (roughly 4%); federal matching funds; reinvested state savings; better use of the "Section 125" federal tax credit; a $2-per-pack tobacco tax increase; and potentially some contribution from counties as medically indigent adults are covered by the state.
* CHANGE FROM AB8: The previous legislation was constrained to revenues only achievable in a majority vote bill, and did not include the hospital or tobacco taxes.
* DIFFERENCES WITH GOV’S OCT. PROPOSAL: Governor’s proposal has a lower employer contribution of four percent, but higher – and possibly unlimited – contribution from workers and individuals. Instead of a tobacco tax, Schwarzenegger’s proposal derives additional revenues from leasing the state’s lottery.
* COMMENT: Most of the financing elements would be put before voters in November 2008.

COST CONTAINMENT

* AB X1 1: A combination of many (but not all) of the ideas from the legislature and the Governor. Requires prevention efforts, transparency so providers disclose cost and quality information, bulk purchasing of prescription drugs, health information technology and a public insurer to compete with private plans.
* CHANGE FROM AB8: The proposal adds language from the Governor's proposal around health information technology, e-prescribing; obesity; smoking cessation; and community makeover grants.
* DIFFERENCES WITH GOV’S OCT. PROPOSAL: Include cost containment elements that were included in AB8. On transparency, Schwarzenegger’s proposal only sets up an advisory committee to set up disclosure procedure, but no long term follow through. The Governor's proposal does not include prescription drug bulk purchasing, nor a public insurer option.
* COMMENT: Cost containment remains a central focus for health advocates. Without addressing the underlying cost of health care, health inflation will continue to outpace wages and cost of living increases, rendering any reforms moot within a few years.

AFFORDABILITY

* AB X1 1: For Individuals/families: Assures that the cost of health care (premiums plus deductibles) does not exceed 6.5 percent of income for families up to 450% of poverty ($92,925 for a family of four) For employers: The requirement is scaled to go to 6.5 percent of payroll; many employers pay more now, and will continue to pay more, of their own choosing.
* CHANGE FROM AB8: AB8 restricted premiums and deductibles to 5 percent of income. All businesses had to pay the same amount under AB8.
* DIFFERENCES WITH GOV’S OCT. PROPOSAL: The new proposal extends subsidies and support to a greater swath of Californians, making health care more affordable.
* COMMENT: Affordability has been the key issue for health advocates – particularly if there is any requirement to take up or buy coverage. Californians should not be penalized for not purchasing coverage they can’t afford, can’t get and provides little or no value or coverage. Exempting Californians for affordability gives consumers the necessary escape valve against unaffordable coverage. Expanding public programs is a huge boon to many middle-income Californians. And a group purchasing pool could help negotiate lower rates for all eligible workers.

OVERALL COMMENT: While most organizations are waiting for legislative language to be released later this week, Health Access California and some other consumer groups are pleased with the framework as described. It would dramatically secure and expand public program coverage and group coverage for millions of Californians, making coverage more available and affordable in each of the ways that people get coverage-through public programs, on-the-job benefits, or buying it as individuals. The proposal include many elements--on public program reforms, insurance market consumer protections, and cost containment provisions--that if passed in any other year would be a major consumer victory in their own right.

Even with all these benefits, consumer advocates will be vigilant when looking at the full legislative language if any population gets more of a burden than a benefit. The notion of an individual mandate has been controversial, but many of those concerns would be addressed with the concepts described, including strong affordability protections and exemptions; significant subsidies with the ability to get coverage through a statewide purchasing pool, and if this was done in the context of expanded group coverage and a smaller individual market. Issues that will be reviewed by consumer advocates will include the definition of minimum benefits; how out-of-pocket costs are factored in either the minimum standards or the affordability protections; the nature of the affordability test; and the structure of the statewide purchasing pool.

PROCESS: AB X1 1 is expected to be formally introduced on Thursday, November 8.

On November 14th, the Assembly Health Committee will convene a hearing on the bill. Speaker Fabian Nunez said he hopes to have a floor vote on the measure by the week after Thanksgiving.

For more information, contact the author of this report, Hanh Kim Quach, at hquach@health-access.org

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posted by Anthony Wright | Permalink | 2:27 AM


 
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Who's listening at the first committee hearing...

Tuesday, November 06, 2007
 
Assembly Speaker Fabian Núñez has listed the names of those Assemblymembers on the special session version of the Assembly Health Committee. It only has a few changes from the Committee of the regular session, with the additions of Assemblymen Mark DeSaulnier and Mike Eng, and the removal of Assemblywoman Loni Hancock.

Here's the list. They are expected to hear the new proposal on November 14th.

Assemblyman Mervyn Dymally, Chair (D-Los Angeles)
Assemblyman Alan Nakanishi, Vice Chair (R-Lodi)
Assemblyman Karen Bass (D-Los Angeles)
Assemblywoman Patty Berg (D-Eureka)
Assemblyman Hector De La Torre (D-South Gate)
Assemblyman Kevin De León (D-Los Angeles)
Assemblyman Mark DeSaulnier (D-Concord)
Assemblyman Bill Emmerson (R-Redlands)
Assemblyman Mike Eng (D-Monterey Park)
Assemblyman Ted Gaines (R-Roseville)
Assemblywoman Mary Hayashi (D-Castro Valley)
Assemblyman Ed Hernandez (D-West Covina)
Assemblyman Bob Huff (R-Diamond Bar)
Assemblyman Dave Jones (D-Sacramento)
Assemblywoman Sally Lieber (D-Mountain View)
Assemblywoman Fiona Ma (D-San Francisco)
Assemblywoman Mary Salas (D-Chula Vista)
Assemblywoman Audra Strickland (R-Moorpark)

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posted by Anthony Wright | Permalink | 11:22 PM


 
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Quick take...

 
What's my quick take on the new proposal?

While we have yet to see legislative language, the framework of the new proposal provides more help to more people to help them get affordable health care than either the Governor’s plan or the legislative leaders’ previous proposal.

* The new proposal would expand public program coverage not just to children and parents, but low- and moderate-income adults without kids as well. It's the biggest public program coverage expansion since Medicare, maybe even including Medicare.
* It would raise Medi-Cal provider rates, to benefit the health system on which we all rely, and to expand access for those on Medi-Cal.
* It would allow for subsidies up to 450% of the federal poverty level, and provide a statewide purchasing pool, so that people get coverage that is both affordable, and negotiated by a group purchaser.
* There's a minimum benefit of a broad benefit package (Knox/Keene plus prescription drugs), and that it can be defined upwards from there.
* The proposal combines the good prevention and cost containment elements of the Governor's proposal (e-prescribing, health information technology, prevention on obesity and tobacco use) with the strong cost containment elements of AB8 (trasnparency, bulk purchasing of prescription drugs, a public insurer option).

In addition to providing more benefits to more Californians, the proposal seeks to spread the risk and cost more broadly, with multiple funding sources. While we are still looking at the details, this is a fair framework, making coverage more available and affordable in each of the ways that people get coverage, through public programs, on-the-job benefits, or the individual market.

ON INDIVIDUAL RESPONSIBILITY: Perhaps the biggest philosophical issues for consumer groups was the individual mandate. The questions was never individual responsibility… people want coverage, desperately.

The question and concern was about the affordability and value of coverage, and the new proposal takes major steps in answering those questions. The affordability protections in the new proposal is a major step, and sorely lacking in the Governor's proposal. We still have questions about how this would work, and so are looking to the legislative language.

ON THE POLITICS: The legislative leaders moved much more signficantly toward a deal than the Governor did when he modified his proposal a few weeks ago. This proposal meets all the issues the Governor raised when he vetoed AB8, and then some. It’s now time to see if the Governor is willing to meet the promise of his rhetoric, of making sure that people can get affordable coverage, by adopting this framework.

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posted by Anthony Wright | Permalink | 1:43 PM


 
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The 50-50 Solution

 
The new Nunez/Perata proposal has both employer and individual requirements, but also has a limit on that requirement.

When the Schwarzenegger plan came out, one of my main critiques on day one was that most stakeholders (employers, providers, counties, etc.) in the Governor's plan had a limit on how much they had to contribute (4% of payroll, 2% of revenue, etc.), but that the individual contribution was unlimited: if you were unsubsidized, you needed to go get coverage, regardless of what it might cost.

Under the new legislative proposal by Nunez/Perata, employers and consumers have required contributions are both limited to 6.5%. Many spend more now, and will likely choose to continue to do so. But the requirement is capped, and at a similar amount.

When Governor Schwarzenegger was campaigning against Prop 72, and then last year when campaigning for Governor, he stated that he was opposed to SB2/Prop 72 not because he was opposed to any requirements on employers, but he didn't like the 80-20 split. He said he would prefer something like "50-50." I believe Jon Myers at KQED has that on tape.

Now he's got it. He has it in a package that includes a multiplicity of other funding sources beyond employers, including a hospital fee and a tobacco tax. The question is, what will he do with it?

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posted by Anthony Wright | Permalink | 10:02 AM


 
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Leg leaders make another offer...

Monday, November 05, 2007
 
So tomorrow, Speaker Nunez and Senate President Perata unveil their new proposal for health care reform.

I don't have lots of details, but here's what I've been able to gather:

* It retains the structure of AB8, including several of its cost-containment provisions, but with significant changes:
* As in AB8, there's a public program (Medi-Cal) expansion up to 300% of FPL for children and adults. But now it also includes adults without kids at home up to 250% FPL.
* In addition to the public program expansion, there would be a tax credit up to 450% of FPL so people could afford coverage.
* The minimum employer contribution would be 6.5%, with a sliding scale of 2% (under $100K)and 4% ($100K-250K) for small businesses.
* It includes an individual mandate, but would exempt people whose health care costs exceeded 6.5 percent of their income; there would also be hardship exemptions for others on a case by case basis.
* It includes the hospital fee, and the associated increase in Medi-Cal provider rates.
* It includes a $2.00 tobacco tax is projected to raise $1.8 billion (after backfilling for revenue to existing programs from previous tobacco taxes).


More details (and commentary) later.

It certainly seems the legisaltive leaders have moved significantly toward the Governor's proposal---much more than what the Governor did toward AB8 when he made his "revised" proposal a few weeks ago. If this isn't the final offer, it's probably close.

Is this the deal? No word on the Governor's reaction.

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posted by Anthony Wright | Permalink | 5:10 PM


 
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The SCHIPs are down, the kids may be out...

 
HEALTH ACCESS UPDATE
Monday, November 5, 2007


MRMIB TAKES PRELIMINARY STEP IN DISENROLLING CHILDREN FROM COVERAGE
* MRMIB adopts emergency regulations to allow for waiting periods and disenrollment
* President Bush's SCHIP veto and standoff with Congress creates uncertainty
* CA's Healthy Families program could disenroll children at their annual reviews
* Children could begin losing Healthy Families coverage as early as December 31


New on the Health Access Weblog: BREAKING: Summary of Nunez's New Proposal on Health Reform (Analysis Forthcoming); Special Session Update: More Reports from Last Week's Hearing; Text or Treat; More on SCHIP and MRMIB; Sec. Leavitt's Blog; GuilianiCare;


In the wake of President Bush's veto of SCHIP and the stalemate over the reauthorization of the federal children's coverage program, board members of California's Managed Risk Medical Insurance Board (MRMIB) on Monday took the first step that would enable the state to put children eligible for Healthy Families on a waitlist, or begin disenrolling eligible children from the program altogether.

Emergency Regulations adopted on Monday can be found here. Healthy Families enrolls approximately 830,000 children in families with incomes between 100% and 250% of the federal poverty level ($20,650 to $51,625 for a family of four).

MRMIB Executive Director Lesley Cummings first broached the topic of creating waitlists and disenrolling children from the program last month after President Bush vetoed legislation that extended the sunset for the State Children’s Health Insurance Program (SCHIP) and would have provided an additional $35 billion over five years to maintain and expand enrollment. SCHIP expired on September 30. Since then Congress and Bush have been at impasse over the program with lawmakers sending the president a largely similar measure to the previously vetoed legislation last week. The new bill is also expected to be vetoed.

Since the September expiration of the SCHIP program, which funds Healthy Families, California has been using up money it has had in reserve from this program. That money, however, runs out on November 16, Cummings said. Healthy Families receives $2 federal dollars for every $1 state dollar put into the program. The 07-08 state budget has appropriated $392 million from the state’s general fund for the program.

Cummings said if the board failed to make a decision and continued operating the program as usual, Healthy Families would run out of money and shut down completely from July 2008 through September 2008.

She and other board members emphasized, ad nauseum, that Monday’s adoption of emergency regulations did not necessarily mean that waitlists would be established or children would lose coverage.

“What we’re talking about today is just the tools to allow MRMIB to take action,’’ said Ruth Liu, who works for Gov. Arnold Schwarzenegger’s administration.

ADVOCATES PLEAD FOR MORE TIME

While advocates who gave public comments recognized Cummings and her staff for their careful stewardship of the program and acknowledged that the under funding of the Healthy Families Program was a problem created at the federal level, all advocates urged the board to take no action to adopt emergency regulations at this board meeting. Instead, advocates asked that the board wait until the actions of the Congress and the President made the policy options clearer.

Their comments centered around the following key points:

* All of the speakers acknowledged that they understood that the board’s action would not result in actually invoking waiting lists or disenrollment actions immediately. However, advocates argued that giving MRMIB the capacity to implement those drastic cost-saving measures was premature at this time. They noted that policy and funding negotiations were ongoing in Washington , and while there clearly were uncertainties, there was still hope for a successful veto override vote or broader support for a compromise proposal.

* Advocates argued strenuously that this was a policy decision more appropriately made by the legislature and the governor, rather than the MRMIB board and the director. There has been recent precedent for the state to step in with financial assistance when problems arose with a federal program. Both the California legislature and the governor did provide financial aid last year during the first year of Medicare Part D, the prescription drug program. They took action when both the new federal law and the many implementation problems resulted in significant delays in receiving their drugs as well as financial hardships for California ’s most vulnerable seniors and people with disabilities.

* Much of the testimony to the board argued for no action until advocates could review the revised emergency regulations. This minor delay would give the director time to consult closely with other states that were facing similar funding shortages regarding their experience. In addition, many felt the board’s decision should at least be delayed until mid-November or preferably the end of the month during a time when the most intense negotiations are being undertaken in Washington which might make these very drastic actions unnecessary. Advocates made several offers to work with MRMIB to pursue additional policy options and remedies to avoid the imposition of waiting lists and disenrollments.

Others also pointed out the irony of restricting coverage for children in the same year that the Governor and Legislature are proposing to reform the health system and expand coverage to millions more Californians – including children.

“I’m a little confused by this conversation,’’ said Angela Gilliard, advocate with the Western Center on Law and Poverty. “To say that we might have to disenroll and limit enrollment seems like this discussion is taking place outside of the health reform discussion in California where we’re talking about expanding coverage’’ to all children.

Board members said they understood angst from advocates, but were torn.

“This is the most abhorrent situation for any of us to be in,’’ said board member Sophia Chang, who works for the Senate Rules Committee. But, Chang said, pleas by advocates to delay a decision “It’s a gamble. To ask us to delay could mean that we have to shut down abruptly’’ causing interruptions in coverage in more children’s lives.

According to independent analysis, the longer the state waits and continues to spend money on the program without assurance from the federal government for additional funding, the more children will be harmed later. If the President had his way with his proposal:
* 260,000 children would have needed to be disenrolled immediately last week (on 11/1), OR,
* 433,000 children would need to be disenrolled by 1/1/08; OR,
* Healthy Families would shut down, and disenroll all 830,000 children 7/1/08.

Deena Lahn from the Children’s Defense Fund and 100% Campaign, said advocates weren’t saying the state should never make a decision. ”We aren’t saying we can wait forever,’’ but Lahn said, “we’ll know more by November 16,’’ and there’s no reason to rush. Since the board’s first meeting on the topic on October 24th, Lahn said MRMIB staff has made positive changes to help clarify the regulations. “There are more improvements to be made,’’ she said.

Other advocates who spoke against the emergency regulations included Health Access California and Community Health Councils, Inc.

However, after minimal discussion, the chair moved and the board voted to approve the emergency regulations. They did adopt one additional provision to revise the proposed regulation to reinstate previously enrolled children first, before new applicants, when funding was ultimately reauthorized.

THE MECHANICS OF WAITLISTING AND DISENROLLING CHILDREN

With Monday’s adoption of emergency regulations, MRMIB can begin as early as December 5, though Executive Director Cummings said any formal actions to constrain enrollment likely wouldn’t start until the end of December.

Responding to critiques from the October 24th meeting that the regulations were too vague, MRMIB also drafted more explicit regulations that explained how waitlists and disenrollment were to unfold.

If the board does establish that Healthy Families does not have enough money, it would:
* First establish a waitlist for new applicants who have not yet been enrolled.
* If the waitlist is not enough, then children’s coverage would be terminated in the month of their “Annual Eligibility Review,’’ the anniversary of their enrollment.

Once, however, money does become available, children who were disenrolled would be re-enrolled in the program, in the order that they lost coverage. After disenrolled children regained coverage, then children on the waitlist, who had not previously been enrolled in the program, could obtain coverage.

For more information, contact the authors of this report, Elizabeth Abbott, project director, at eabbott@health-access.org, or Hanh Kim Quach, policy coordinator, at hquach@health-access.org.

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posted by Anthony Wright | Permalink | 5:09 PM


 
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Elections have consequences...

 
President Bush's veto of SCHIP took one step closer to having a real impact in California today.

The Managed Risk Medical Insurance Board (MRMIB) voted today to implement emergency regulations to establish waiting lists and disenrollments of children from California's SCHIP program, called Healthy Families.

They aren't kicking off kids coverage yet, but we are getting damn close... We'll have a full report later today.


As for why we are in this mess (and to get angry), check out Health and Human Services Secretary Michael Levitt's blog, where he tried to defend the President's decision. He somehow thinks "express lane enrollment" (expediting the application process for children on school lunch programs so they can get coverage) is a secret path to single-payer; and he responds to my Massachusetts' colleagues critique with funny numbers to hide the key fact: President Bush's proposal simply doesn't have the money to keep the currently-enrolled children in California's Healthy Families covered, much less enroll those uninsured-but-eligible California children.

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posted by Anthony Wright | Permalink | 3:03 PM


 
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GuilianiCare

 
The former mayor of my hometown, Rudy Guiliani, is downright scary in his pronouncements on health policy issues. And my suspicion is that he knows better, which makes me think even less of him.

Sara Mosle at Slate compares the lessons he learned from his prostate cancer experience now, and what he said and did at the time.

Paul Krugman at the NY Times and San Jose Mercury News is also merciless on his use of blatant misinformation.

posted by Anthony Wright | Permalink | 2:34 PM


 
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Throwing kids overboard?

Friday, November 02, 2007
 
The Managed Risk Medical Insurance Board on Monday will consider adopting emergency regulations that would enable the state to establish waiting lists and begin disenrolling children from Healthy Families, the state's program for low- and middle-income children, as early as December 5.

At the October 24 meeting, board members deferred a decision on the emergency regulations until more information from Washington -- and the reauthorization of the State Children's Health Insurance Program -- was forthcoming. Advocates also offered other options, as spelled out in this report, and pointed out that the Legislature should weigh in before the state begins kicking children off coverage -- particularly during the year of health reform.


The situation on Capitol Hill has been bleak, according to news reports, and the President is expected to veto another bill that would extend the SCHIP. The latest congressional bill would have given California enough money to sustain its Healthy Families program, which enrolls 850,000 children.

According to independent analyses, if the President had his way and funded SCHIP with only the $5 billion increase:


  • 260,000 children would need to be disenrolled immediately 11/1 (next week); OR,
  • 433,000 children would need to be disenrolled by 1/1/08; OR,
  • Healthy Families would shut down, and disenroll all 830,000 children 7/1/08.

To avoid the ensuing calamity, advocates should get their comments into the Managed Risk Medical Insurance Board ASAP!

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posted by Hanh Kim Quach | Permalink | 3:48 PM


 
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The full report on a full hearing...

Thursday, November 01, 2007
 

HEALTH ACCESS UPDATE
Thursday, November 1, 2007

ASSEMBLY HEALTH COMMITTEE REVIEWS GOVERNOR'S HEALTH PROPOSAL

  • Assembly Speaker announces intent to vote on a new health care bill by Nov. 26
  • Legislators and stakeholders grill Gov's health plan on affordability, financing
  • Despite questions, many agree: Don’t lose momentum. Get something done this year.
  • Thousands of Californians from across the state send text messages to Gov. Schwarzenegger urging health care reform

Gov. Arnold Schwarzenegger’s health legislation was vetted over five hours on Wednesday by the Assembly Health Committee, which examined key aspects of the proposal – including whether it would be affordable to consumers, whether it would help drive down health care costs, and whether it had enough financial backing to keep it afloat.The informational hearing did not result in a vote--no legislator agreed to author the proposal for it to be a bill--but the event did allow lawmakers to delve into 220-page tome and hear from consumer advocates, doctors, hospitals, insurers and other stakeholders about the legislation’s far-reaching impacts.

A deal, however, is attainable, said Assembly Speaker Fabian Nunez. “In areas where we disagreed, the Governor has made movement and he should get acknowledgement for the movement he has made,’’ Nunez said. He said he wanted the Legislature to strike a deal with the governor and vote on a health care proposal by Nov. 26.

The desire for movement was palpable on Wednesday as hundreds of consumers involved with the It's Our Healthcare coalition arrived at the Capitol to watch the hearing, in various overflow rooms around the Capitol. The coalition also set up a giant screen facing the Capitol that allowed thousands Californians to text message the governor about the need for health care reform this year, and broadcast their message on the screen that could be viewed live on http://click.icptrack.com/icp/relay.php?r=1012041699&msgid=3725529&act=XIOO&c=5484&admin=0&destination=http%3A%2F%2Fwww.itsourhealthcare.org&l=2 .

BACKGROUND AND THE MAKING OF SCHWARZENEGGER’S HEALTH PLAN

While the legislative hearing on Wednesday focused on the Governor’s proposal, Schwarzenegger’s legislation is not the only health reform bill on the table this year. In September, the Legislature passed AB8 (Nunez/Perata), which would have provided health coverage to approximately 95 percent of Californians. AB8, however was vetoed by Gov. Arnold Schwarzenegger in mid-October. Before 2007, the Governor has vetoed legislation that would create a single-payer health care system (SB840) and provide universal health care to all children (AB772). In 2004, Schwarzenegger also aggressively campaigned against Prop. 72, which would have required all businesses with more than 50 workers to provide health coverage. After the past several years of rejecting reform measures, Schwarzenegger made a commitment to work on the issue in 2007, releasing a 10-page concept paper in January. In October – 10 months and thousands of meetings later, came the release of the Legislative draft.

This Assembly Health Committee hearing was the first opportunity to review the draft in its actual detail. The Committee has a full analysis of the draft, as well as an agenda for the day. Some key concepts in the governor’s proposal are:

  • Individual mandate: The governor would require all Californians to have health coverage, without condition, limit or exception. Everyone would be automatically enrolled in some plan, and the state would later recover money for the premiums, enforcing the mandate through various agencies. The “minimum credible coverage” is no longer defined; instead the Secretary of Health and Human Services will define it, although employer-based coverage would count even if it was below the minimum.
  • Public program expansions: Expands public programs for all children up to 300% of the federal poverty level, and many qualified parents and adults without children at home up to 250% of the federal poverty level ($25K for an individual, $50K for a family of four). Some streamlining of these programs. Allows low-income adults and families up to 150% of the poverty level, to qualify for no-cost Medi-Cal. ($15K for an individual; $30 for a family of four)
  • Minimum employer requirement: Requires that employers of more than 10 workers spend at least 4% of payroll for health care benefits. Employers with fewer than 10 workers would be required to contribute on a sliding scale of 0-4% of payroll.
    Insurance market rules: Insurers would be prevented from denying people based on “pre-existing conditions,” phase in restrictions on charging people more for their health status, and have to spend 85% of the premiums they receive on all their plans on patient care, rather than administration and profit.
  • Provider rates and fees: Medi-Cal rates would be increased for doctors and hospitals. Hospitals would be required to pay a “dividend’’ in the form of a 4% provider fee. Doctors would not be assessed such a fee, as originially proposed.
  • Lottery: The state would lease lottery operations to a private company to raise about $2 billion/year to help finance the program.

LAWMAKERS: WORK STILL NEEDS TO BE DONE
Individual Mandate

Lawmakers from both parties asked wide-ranging questions to seek clarification and air their thoughts on the governor’s bill.Assemblywoman Karen Bass asked about the individual mandate: “How can it not be punitive?”

The administration’s Health and Human Services Secretary Kim Belshe called the mandate “a partnership approach.’’ Belshe said she hoped that employers, community-based organizations, schools and providers, would all work together to help build a “culture of coverage’’ that encouraged and educated Californians about how and where to obtain health insurance.

Assemblyman Bob Huff, however, pointed out that the state currently has an auto insurance mandate – yet 25% of Los Angeles drivers (approximately 14% statewide) – do not carry auto insurance. Huff expressed concern that Californians would not comply with the mandate and wait until the last minute – when they get sick – to obtain coverage. And if insurance market reforms go through – and insurers are required to issue coverage to anyone that applies “doesn’t that drive up premiums for everyone else?’’ since only sick people would have coverage, Huff asked. Huff was also concerned about the state’s ability to recover premium dollars from workers in the “underground’’ economy and who have little tax liability would pay for their coverage.

To address Huff’s concerns, Belshe elaborated more on the administration’s plans. “People want to be insured if it is affordable and available,’’ Belshe said. But should some individuals not comply with the mandate, they would be automatically enrolled in the most basic plan. Our goal is to “maximize enrollment’’ and that would also include a “premium recovery strategy’’ that would essentially harness the premium cost from a workers’ pocketbook and “using at their contact with the outside world to get their money.”

Affordability
Many lawmakers said they were concerned about whether the plans would be affordable for Californians and did not like the idea that the governor’s proposal did not establish a minimum benefit package that assured them that families would receive a good value for their premium dollar."How do you define affordable coverage, specifically,’’ asked Assemblyman Kevin De Leon. “Is it premiums? Is it out-of-pocket costs? Is it premiums plus deductibles? This is important to me. Where my constituents live, they have to worry about how to pay for gas, car and electricity,’’ he said. “Affordability is a really critical question.’’

Belshe said the administration agreed that affordability was an issue. “Today, healthcare is just not an affordable option. That’s why (the governor) has built in very strong affordability provisions,’’ which she said included public programs expansions, subsidies and tax credits. But Belshe also admitted there were differences of opinion over where lines on affordability should be drawn. The administration and legislative leaders are still discussing whether a cap should be imposed at the premiums or out-of-pocket costs.

“That’s a point of difference and ample opportunity for robust conversations. We need to think through a couple of things,’’ Belshe said. “What is the cost of looking more expansively? How would it be financed and at what expense to other (state) general fund priorities?”

Assemblyman Mark Leno was particularly concerned with families above 350% of poverty ($72,300 for a family of four) who would be required to buy coverage, but with no tax credit or subsidy to help. Belshe said, however, that employers would be required to allow workers to use pre-tax dollars to buy coverage – a move that could save families up to 33% on their premiums. But Leno seemed unconvinced. “It still seems to me that the employee’s cost is going to be more than $7,000 as well as deductibles of as much as $10,000,’’ he said.

At a minimum, Belshe said, caps on out-of-pocket costs would give families catastrophic protection. “Now, a family a exposing themselves to bankruptcy because they have no protection whatsoever.’’ As consumer advocates pointed out later, it is important to note, though, that 60 percent of all Americans have less than $12,000 in liquid assets, which would mean a $10,000 cap on costs (on top of a premium) would wipe out their savings.

Cost containment:
Lawmakers also examined whether the plan would rein in the underlying costs of health care – what causes health inflation to increase at rates three times that of wages or the price of other goods. Assemblywoman Mary Hayashi asked why the governor’s proposal did not set up a system to purchase prescription drugs in bulk in the same way that AB8 did. Belshe said that such a mechanism wasn’t as acutely necessary because Californians would have health coverage – and therefore would not pay as much for drugs. “No one pays more for prescription drugs than the uninsured. Why? Because they’re buying on their own. Under the governor’s plan, the’re insured, so they have cheaper drugs,’’ she said.

However, the governor’s plan does not specify what benefits should be included in a minimum benefit package. Many high-deductible policies do not have prescription drug coverage, leaving those individuals to continue paying top-dollar for prescription drugs. In addition, AB8 did allow for the statewide purchasing pool to use its full purchasing power to negotiate for the best possible prices.

Assemblyman Dave Jones, the author of a bill earlier this year that would have instituted rate regulation of insurance premiums, hammered away tirelessly on issues of containing premium costs. In one exchange, Jones extracted an admission from the HealthNet lobbyist that premiums would likely increase, regardless of whether there was an individual mandate.

“There’s nothing in Governor’s proposal that provides for regular review or a cap on rates. At the end of the day, it is a proposal that requires everyone to buy insurance from you, but there’s no restraint in the price you can charge them, I can see why you might like that plan,’’ Jones said.

Belshe, however, said she did not believe that premiums needed to be regulated or restrained – and that competition among insurers would drive down premiums. “The governor has confidence in the market place,’’ she said. She later added that doing nothing about health reform this year “will assure that the relentless increases will continue.’’One thing lawmakers believed could help contain costs – at least for consumers – was further definition of the “minimum benefit package,’’ which would allow consumers to know the minimum value of the plan they would be required to buy.

The governor’s latest proposal requires Belshe to oversee a process to define a minimum benefit package. Lawmakers said such a process left them uncomfortable and concerned.

Assemblywoman Fiona Ma ticked off a number of diverse needs that patients have in health care. “How can we be assured the minimum benefit package would address off lf these?’’ she asked.

“It’s a fair question,’’ replied Belshe, “but what we heard (from those they met with) was that they favored an open, public participatory process that wasn’t too prescriptive.’’Assemblyman

Jones, was unconvinced. “I understand the process, but to ask without more assurance with respect to what the content of plan would be is a great leap.’’

Other issues

The wide ranging discussion also touched on:

  • the adequacy of the lottery funds to pay for reform (the Legislative Analyst’s Office raised concerns about this possibility),
  • whether the plan violated the federal law that bans states from dictating how businesses provide benefits (Belshe said it doesn’t and the law was crafted to minimize exposure to legal challenge),
  • how the plan dealt with health disparities within communities of color (Belshe said she hoped the emphasis on prevention, obesity, healthy living and tobacco cessation would help),
  • whether there would be adequate physicians to take care of the newly insured and whether access to health professionals would improve (Belshe indicated that many uninsured get care not but not in the mose efficient way; she also said that’s where the role of retail clinics, staffed by nurses and physician assistants would come in hand).


THE PLAYERS COME TO THE TABLE AGREE – ON ONE THING

The Assembly committee later heard from all sectors of the health care debate, on a variety of topics divided by panel, including:
* the role of individuals and employers
* private health insurance markets
* government programs,
* cost and quality,
* and finally, general public comment.

While opinions about how the Governor’s plan would impact consumers and play out in the long run differed, they all agreed that the state should not squander the momentum this year to accomplish reform.

“We can get this done. We need to make use of the optimism of 2007 and make sure it does not slip to political cynicism in the election year of 2008,’’ said Mark Weideman, vice president of Blue Shield of California.

The ground staked out by groups, however, was familiar territory. Some businesses said they agreed with the Governor's approach, and feared a bigger employer mandate would drive businesses from California, or cause them to cut jobs or go out of businesses. Insurers insisted they needed an individual mandate to assure they received premiums from both younger and healthy Californians, in addition to people who needed more health coverage.

Many consumer, constituency, and labor groups, including members of It’s Our Healthcare! continued to make constructive suggestions on points that have been raised all year, especially in comparison to

AB8(Nunez):

  • Affordability: AB8 conditioned any requirement to take up coverage to a percentage of income (5 percent) for health spending (premiums plus out-of-pocket costs).
  • Employer responsibility: AB8 required 7.5 percent of payroll rather than the governor’s 4 percent, to assure that workers who get coverage had more security in their coverage, that resources that employers already spend were maintained to keep the financing of health care viable; and that too much burden wass not shifted onto workers.
  • Cost containment: AB8 included several key elements to help contain costs, including prescription drug bulk purchasing, the option for a public insurer to compete with private insurers, cost and quality data collection and disclosure, prevention, and other methods.

Consumer and community groups that spoke – both on a panel or to offer public comments on the governor’s plan include: Health Access California, California Labor Federation, Service Employees International Union, AARP, CALPIRG, Consumers Union, California Pan-Ethnic Health Nework, California Association of Public Hospitals, Children's Defense Fund and the 100% Campaign, Western Center on Law and Poverty, California Primary Care Association, Insure the Uninsured Project, AFSCME, American Cancer Society, Health Officers Association of California, California Chronic Care Coalition, Foundation for Taxpayer and Consumer Rights, California Nurses Association, Children’s Specialty Care Coalition, Children’s Health Initiatives, Jericho, California Alzheimer’s Association, Moms Rising, American Diabetes Association, Latino Coalition for a Healthy California, California Immigrant Policy Center, Community Health Councils, Inc., Congress of California Seniors, California School Employees Association, Carpenters Union, Planned Parenthood of California, and others.Other groups, such as the California Medical Association, California Hospital Association, insurance brokers, pharmacists, and counties also spoke as well.

For Health Access California's 15-page letter on the Governor's health reform, and other analyses and resources about health reform, visit the Health Access website at:
http://click.icptrack.com/icp/relay.php?r=1012041699&msgid=3725529&act=XIOO&c=5484&admin=0&destination=http%3A%2F%2Fwww.health-access.org%2Fadvocating%2F2007_healthdebate.html&l=4


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posted by Hanh Kim Quach | Permalink | 11:08 AM


 
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Early reviews...

 
Here's some early reports on the Halloween hearing on health care, from the San Jose Mercury News, the Sacramento Bee, and the Ventura County Star.

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posted by Anthony Wright | Permalink | 2:52 AM


 
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Anthony Wright is the executive director,
with a background as a consumer advocate and community organizer on many issues, including health issues for the last ten years in California and New Jersey.